Insurance Billing Basics: The complete guide to getting started with insurance for private practice

Hi welcome to insurance billing basics I'm Jill shook I'm a speech-language pathologist in private practice in Pittsburgh Pennsylvania when I started my practice I went through the decision-making process of deciding if I wanted to accept insurance so I thought I would give you some basic information so that you too could decide if you.

Would like to accept insurance or not it seems like a very complicated process and it can be but it's also pretty simple if you get right down to it the first thing that you want to know is some of the basic vocabulary being speech pathologists we have a lot of abbreviations and billing is no different so we'll go over some of the.

Basic vocabulary you'll have to learn about EMRs or EHRs you'll hear that a lot those are electronic medical records electronic health records they're basically the same thing that's where you'll store all of the information for your clients it'll have their patient information it will have your.

Documentation you can also usually communicate with your clients in a secure and HIPAA compliant manner next you'll have to know about er a S which are electronic remittance advice that means the online information that you will get from the insurance company about the bill or about the EOB which is the explanation of benefits so.

An ER a is basically the online version of an EOB gops are usually paper and they will send those to you so you can save some trees and have them do an e re for you you'll need to know what a claim is so a claim is basically the information that you're sending to the insurance company about what you're billing for so if you have you know a.

Session with the client you will send that information to the insurance company and they will pay for it how you hope it works there's also superbill and you'll hear invoice in general people throw those around as meaning the same thing and they kind of are a claim is just basically here's the invoice insurance.

Company of what I did and then you can pay me per the contract that you have with that patient a claim is that and then a super bill is what you can submit to an insurance company when you are not an in-network provider with them so it's basically a receipt that the client can submit saying this is work that I had done I paid for an out of pocket and now.

Insurance company I would like you to reimburse me for that so that's what a super bill is and you can also you hear the word invoice for super bill but we like to use the word superval because invoice can be really anything I mean you can get an invoice for dinner you could get an invoice for something you buy online.

Super bill is really what you want to use if you're talking about that out of network claim next you'll have to know about clearing houses those are basically intermediaries between you and the insurance company and they check claims for accuracy and they let you know if anything needs to change before it gets sent on to the insurance company.

They're a middleman but they're required and they are what you will basically submit your claim to so that it can be then given to the insurance company so now that you know the basic vocabulary you can get into the process of billing and in order to bill you have to be credentialed with an insurance company credentialing is just the process by.

Which the insurance company decides if you are approved to be a provider with them so it's kind of like applying for a job you send in a resume which for you is on what's called CA qh pro view when you set up your CA qh pro view account you'll need some basic information about your business you'll need your business name obviously you'll need your name.

Your Asha number your state license number your EIN that's basically your social security number but it's for your business because you don't want to be sending your social security number to everyone you can apply for that via the IRS and it's free and takes about five minutes you'll also need your NPI your national provider identifier and the.

Information about your professional liability insurance they're basically checking if you're in good standing with all of the licensure requirements that you have and also that you have you know professional liability insurance or anything to happen then you'll fill out provider information forms for whichever insurance companies you'd like to work.

With the insurance companies will take that information that you fill out in your form and then also in CA qh pro view and decide if they're going to allow you to become a provider they decide that based on varying factors that includes how many providers are already in your area and then also you know if they need providers in a certain.

Specialty or not in 30 to 60 days you can decide you can find out if you have been credentialed by the insurance companies so after you get the happy information that you have been accepted to be a provider with the insurance company that you'd like what you want to do is check the contract that they will send you to see what their fee schedule.

Is now most insurance companies will give you that fee schedule after they have approved your becoming a provider before you have signed your contract because you want to know what their fee schedule is what they would pay you what the rates are before you decide officially to become a provider some of them do allow you to look up a fee.

Schedule on their website without having to become a provider but in general you'll have to go through their kind of provider credentialing process in order to see that information so you'll take a look at the information you'll say you know do I like these rates you know do I think that these are workable and then if you do you can go ahead and accept.

The contract and then you'll be a provider with that insurance company now being a provider with them means you have to abide by their contracts so you definitely want to make sure you look at your contract see what requirements they have some of them can have varying requirements such as CPT code hourly requirements as you know most of our.

Codes are not timed like 9:00 to 5:00 o 7 just general therapy is not timed however some insurance companies require that you have an hour long session to build that make sure you look at that so that you're not fraudulently billing you know say if you have a 30-minute session and you build that code that would be fraudulently billing for them you also.

Want to make sure that you understand how to check eligibility for the insurance companies and generally you'll use the Clearinghouse like we talked about earlier but some insurance companies have specific clearinghouses specific required requirements so you want to look at that to make sure you understand exactly what.

Each insurance company requires so after you have become a provider you've been credentialed you become a provider now you have a client they call you and say hey I have this insurance and you say great I take this insurance there are some information that you'll want to get from the patient so that you can verify their benefits and make sure.

That yes you take their insurance but does this insurance actually cover what they're wanting to come to you for so you'll want to get their insurance number you want to get their date of birth and you'll want to get their address and phone number as well so after you get the information from your client you'll want to input.

That into your EMR or the Clearinghouse that the insurance has required you'll put their membership ID in there you'll put their date of birth and that will give you their benefits you'll look at the benefits you'll see what their deductible is so you know how much they have to pay out-of-pocket each year before insurance will start covering.

Things you also want to look for any speech therapy requirements so for instance a lot of my clients have come in and they only get a certain number of sessions per year so sometimes that's ten sometimes that's twenty sometimes that's fifty it can be any number but you want to look and see if there are any hard caps on the number of sessions.

Because in general regardless of how much you beg and plead with whatever insurance company they're not going to approve any more sessions if that person only has a certain number of sessions per year once you see their deductible you also want to check for any co-pays or coinsurance that they might have for specialist visits which are you going to.

See a speech therapist coinsurance is a percentage of the rate that they would have to pay so to make the numbers easy because I'm not a math major say your rate would be a hundred dollars for a session the coinsurance would be say ten percent of that so for each session the client would have to pay ten dollars so that would be their ten percent.

Coinsurance and then the insurance would pay the ninety dollar remnant to that so that would be coinsurance if you're looking at a co-payment a co-payment is a flat fee so that'll be a certain amount for you know any visit that the client goes to so you would look for a co-payment for speech and if that was say twenty dollars then every time the.

Client sees you they have to give you 20 bucks and that will be the flat rate that they have so when you look up the insurance information for the client make sure you check their deductible check for any coinsurance or co-payments and then check for any piece limits make sure you have all that information before you start therapy and.

Also share that information with the client to make sure that you guys are on the same page about your understanding of their benefits you don't want to call them and tell you oh I have speech therapy benefits well yeah they might but do they only have ten a year that might not be what they wanted so definitely look into that and make sure.

You guys are on the same page before you start therapy I know it seems like a lot of you know you have the client call you they say you want they want therapy you check their benefits either on the phone or you look on your EMR or the Clearinghouse and then you have to get back to the client and make sure that you guys connect and.

Talk about what their benefits are to make sure you're on the same page but you do this ahead of time you don't have to worry about later having an issue where they didn't understand their benefits or you know they thought they had more sessions or you know they didn't know they were gonna have to pay a copay or coinsurance you want to make.

Sure everything is laid out before you start therapy so that there aren't any surprises after you've seen your client you can go ahead and get your claim ready to submit so in simple practice it's really easy that's why I really like using it all you do is you go to the billing section and you select a date range and then you can create a.

Claim from that they're called the CMS 1500 claim and CMS is just Center for Medicare and Medicaid Services it's just the claim form that has all of the information that you will need to submit to the insurance company the basic information that you'll need is of course the clients name their insurance information your MPI number the location.

At which the services were provided there are location codes that you would use to denote where you've seen your client for instance if you saw them via telehealth it would be a – if you saw them at an office it would be 11 if you saw them at their home it would be 12 make sure that those place of service codes are correct make sure that all the.

CPT codes are correct so that's telling the insurance company what you actually did that's the procedures that you did so make sure that the icd-10 codes your diagnosis codes are correct because on the form they won't have periods in them to like you know f80 point Oh would just be f800 so make sure that those are correct or.

Get kicked back to you as in correct you'll also have the rendering providers NPI number and rendering just means the person who provided the service so if you're a single member or solo practice that's pretty easy that's you you'll use your individual NPI number at the bottom of the form you'll also have the facility information and you'll have.

Your facility NPI number your type two or group NPI number there so after you've created that claim and double-checked it for accuracy you'll go ahead and submit it and then that claim will be sent through to the Clearinghouse which as we discussed before the clearinghouse is kind of where claims go to be double-checked and.

Made sure that everything is correct and if the claim gets denied the Clearinghouse will kick it back to you and say you know this is the reason code for it this is what you need to fix so you want to keep the timely filing requirements in mind while you're filing your claims many companies allow you 365 days from the date of service in which.

To file the claim most clients are not going to appreciate getting a claim from six months or a year ago also you have to make sure that you've checked your contract because some companies do give you only 90 days in which to file the claim from the date of service in general if you do a weekly filing or at the very least a monthly filing you.

Should be well within the timely filing requirements for your claims so if you have to resubmit it's not the end of the world all you'll need to do is hit edit to resubmit simple practice makes that really easy and just click Edit to resubmit and then in box 22 you'll put either seven to resubmit the claim or.

You'll put eight to avoid the original claim and you know you'll have to submit a new one so you want to make sure that those resubmission codes are there or that can really mess up all of your all of your submissions so that's the basics of insurance billing if you have more questions or want more information there are some great resources linked below.


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